Examining WCRI Study on Networks Impact on Claims

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Tom Kerr (TK): Medical costs remain one of the largest drivers of claim expenses, and recent research from WCRI gives us a clearer picture of how networks are influencing not just costs, but access, care patterns and outcomes.

To take a deeper dive into the study, I’m joined by Enlyte’s Kate Farley-Agee, vice president, product management, network solutions, and Heather Tomhave, director of product management.

Let’s start with the first question today. The WCRI study examined how provider networks impact medical costs and claim outcomes. What are some key takeaways? Kate, can you get us started?

Kate Farley-Agee (KFA): Sure, Tom. Thanks. You know, one of the most important takeaways in this study and the way that networks have evolved over time is that networks deliver measurable value across a number of different metrics across claim performance.

So, for example, the study showed that networks reduce medical payments per claim by about 27% and also lower total claim costs by 26%, and that’s when you compare bills and claims that are treated in-network versus out-of-network.

But even more interesting, these savings aren’t just from the discounts that are in contracts between a network and a provider. It also has to do with how well providers who are well-versed in treating injured workers and have a contract with a network treat them from a medical protocol standpoint. With these providers, injured workers are more likely to receive more conservative care rather than jumping directly to more invasive care. And invasive care just means more costs, not necessarily better outcomes.

But depending on the injury and how it presents, these physicians go to something like physical medicine or diagnostic services to really hone in on exactly what’s going on and then go from there. At some point there may be invasive intervention, but because they do these patterns first, we tend to see significant cost reductions in general.

The study also found other measures of success by networks. We see a shorter temporary disability duration overall, about one and a half weeks, when you compare it to similar types of injuries outside of a network. So, that’s between 9% and 10%, and then it also represents a 9% total reduction in disability duration overall.

So, looking at the total picture, it’s not just the rates, it’s also the management of the claim. These improvements contribute to not only lower costs, but better outcomes overall and shorter disability durations.

The other thing I will note is that while networks clearly deliver value, we’ve all experienced that over time, we also know that all networks are not equal because they take different approaches to building their network. So, there’s a stark difference between some networks and the claim outcomes. The savings may or may not be the same, but the claim outcome may be different.

That’s because some networks maintain strong performance over time and really adapt to the market. Not only the client market, but the provider market and regulatory changes that are occurring in the market.

TK: OK, great. And, the research found networks improve access to care, and this is a major issue right now. Heather, why do networks make a difference?

Heather Tomhave (HT): Thanks for having me. So, access to care is quickly becoming one of the biggest drivers for both claim costs and claim outcomes. The WCRI research found that injured individuals treating within a network access care much sooner than those treating outside a network.

Their first office visit happens nearly three days sooner with an average 20% reduction in wait time. This faster access to care is particularly important because previous research has suggested that quicker initial treatment tends to correlate with faster physical recovery and return to work.

TK: And what are some ways Enlyte handles access to care with its networks?

HT: We approach access to care as something that has to be actively managed. We evaluate network performance over time to identify opportunities to strengthen provider access while ensuring pricing remains competitive.

Through all of this, we maintain strong provider engagement. The goal is to ensure the network continues delivering value for payers even as the property and casualty market changes. Because the Coventry Integrated Network is the largest directly contracted P&C network, Enlyte ensures broad and sustained coverage. Our continuous network expansion efforts to identify any gaps in coverage are maintained by our large and effective contracting team spread throughout the country. This local presence is key to maintaining a solid understanding of regional provider dynamics.

The Coventry Integrated Network has really set the standard for all other P&C networks. Our proven network results are coupled with a commitment to developing and maintaining strong relationships with providers. This is proven by nearly a 99.4% retention rate among our contracted providers.

But it’s not just about getting the injured individual to a provider. It’s about making sure they get to the right provider.

TK: Thanks, Heather. And, Kate, what about provider profiling? What factor does that play into a modernized network management strategy?

KFA: It’s really key, Tom, because as Heather just said, it’s key to getting the injured worker to the right provider at the right time. What leads us into that is provider profiling so we can get to that right direction of care. Provider profiling is becoming more important, and it’s because networks continue to evolve.

Like we talked about earlier, it’s not just about the contract rate, it’s about the entire management of the case, the provider protocols and what they’re doing to manage the claim. 

Historically, networks primarily focused on negotiating discounts and also broad access. So, they would just go out and market them, or blanket the market and say, “I want everybody that I can get.”

And that’s great in building a network, but once you get to the point where you’re really trying to focus on the outcome, then you have to really look at who are the more efficient providers. Are they doing the right things, following the right medical treatment guidelines?

And because we now have access to more robust data, and also data analytics tools as technology increases, it allows us to have insight into the direct impact on overall cost and outcomes that the network brings.

And also, good networks do more than just negotiate a price with a provider. It’s really understanding what the provider’s doing that drives better results at the back end. We use data to evaluate treatment patterns. How is the provider looking at an injury? Is he or she doing all tests up front to really hone in on the specific issue and tailor that treatment protocol for that particular injury?

We also look at medical utilization. How is the provider using pharmacy, physical medicine, radiology, or is he or she just going right to surgery? And those factors are looked at differently as we evaluate providers.

We also look at the claim duration and total claim costs to see what the provider is doing in utilization, how is that translating to the bottom line? Coventry, specifically, applies this type of analysis through our base network development strategy in looking at providers to add.

Coventry is a much more seasoned network, and there’s a lot of providers in it, so we’re not blanketing the market. What we’re looking at is where do we need to target our efforts? And so, where are those providers that we really want to have in the network going forward?

It also plays into our outcomes-based network strategy. Providers in the outcomes-based network demonstrate better results and improvements. What we see in this network is that providers drive 40% to 50% lower medical costs in the overall claim and also, 25% to 35% reduction in claim duration.

This allows us to direct injured workers to the providers to get a better result overall. Financial, not only return to work, duration of the claim, lower indemnity. The other thing we saw in the study, if we have tighter management of a claim, we see lower disputes overall and also lower legal involvement.

TK: And that kind of takes us into our next question. Heather, I wonder if you can expand on that a little bit. How do networks help reduce litigation expense per claim?

HT: It really comes down to stability and alignment. When providers are part of a contracted network, their reimbursement expectations are clear, which means billing disputes are reduced. Ultimately, this encourages strong and positive relationships within the provider community.

This clearly shows up in the WCRI research. As Kate said, it found an estimated 12% reduction in litigation rates and nearly 40% reduction in litigation costs for claimants treating within a network. We see this reinforced in our own data. In those rare instances where we receive a dispute, 97% of the disputed payments are upheld.

Again, this demonstrates Enlyte’s commitment to strong provider engagement and long-term cost containment. When expectations are clear, the relationships are strong, and there’s less friction and less legal costs for care delivered and managed through the Coventry Integrated Network.

All of this drives towards ensuring the best possible outcomes for our injured individuals, which is the ultimate goal.

See how a high-performing network strategy can reduce costs and improve claim outcomes. Explore Enlyte’s network management solutions.